Tamil Nadu

North Chennai

103/2012

R.Nagalakshmi, - Complainant(s)

Versus

The oriental Insurance Co. Ltd, - Opp.Party(s)

S.Vijayaraghavan

14 Oct 2016

ORDER

 

                                                                Complaint presented on: 31.01.2011

                                                                     Order pronounced on:14.10.2016

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

FRIDAY THE 14^th  DAY OF OCTOBER 2016

 

C.C.NO.103/2012

 

 

R.Nagalakshmi,

W/o.S.Ramamoorthy,

4/3, II Cross Street,

Lenin Nagar,

Ambattur,

Chennai – 53.

                                                                                 ..... Complainant

 

..Vs..

 

1. The Oriental Insurance Company Ltd.,

W-115, 1^st Floor,

SB Complex Third Avenue,

Above VIP Showroom,

Rountana,

Anna Nagar,

Chennai – 600 040.

 

2.Heritage Health TPA Pvt.Ltd.,

Formerly Heritage Health Services Pvt Ltd.,

1102, Raheja Chambers, 11^th Flooor,

Free Press journal Road, Nariman Point, Mumbai – 400 021.

 

...Opposite Parties

Date of complaint                                   :28.04.2012

Counsel for Complainant                       : S.Vijayaragavan

Counsel for  1^st  Opposite party                : Mr.S.K.Krishnamurthy

 

Counsel for 2^nd Opposite Party                      : Ex - party

 

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1. THE COMPLAINT IN BRIEF:

          The Complainant has availed Overseas Medical Policy while she  was travelled to Chile in October 2008 vide policy No.41220/48/2009/1404 dated 13.10.2008 from the first Opposite Party (i.e) oriental Insurance Co. ltd., for a sum of US Dollars two lakhs fifty thousand had she has also paid a premium of Rupees Four Thousand and Five. While applying for the overseas medical policy she disclosed all her previous medical history. The Complainant stated that she had taken good and proper care of her health by going to the doctor for regular checkup. She has consulted her doctor and had taken his advice for her travel as per the policy requirement. During the stay in Chile the Complainant developed breathlessness, fatigue, chest pain which necessitated immediate medical treatment in order to maintain her health and life and relieve from the pain that she was undergoing. In the course of the treatment several test such as ECG, Blood test, X-rays were conducted to diagnose the extent of illness. In the process of the medical treatment Complainant has incurred a sum of 2,61,738 Chilean Pesos which is approximately 24,090.22 Indian Rupees. These medical events took place on the advice of the treating physician. The overseas Medical policy provides indemnity for expenses necessarily incurred for immediate treatment of illness. Further the policy also clearly states that “Medical related expenses reasonably and necessarily incurred means expenses that in the option of the treating physician are medically necessary in order to maintain life and or relieve immediate pain or distress occurring during the period of insurance.” The policy also covers expenses for physician services, hospital and medical services and local emergency medical transportation. Further, the policy does not exclude the treatment for any existing disease. As per the clause 2 of the GENERAL CONDTIONS APPLICABLE TO ALL SECTIONS IN THE OVERSEAS MEDICLAIM POLICY BOOK issued by the insurance company, it is clearly stated that “in no event should a claim be notified to coris/ Heritage later than 31 days after the end of an insured trip. As per the terms and condition of the policy issued by the 1^st Opposite Party the claims if any arising out of the policy should be made to the 2^nd Opposite Party within 31 days after the end of the insured trip. The Complainant arrived India on 18.01.2009. The Complainant has submitted the claim to the 2^nd Opposite Party for a sun of 2,61,738 Chilean persons which is approximately 24,090.22 Indian Rupees on 30.01.2009, 11.02.2009 and 05.05.2009 along with all supporting document. In response to her claim the 2^nd Opposite Party have by letter dated 26^th March 2009, 11.05.09 stated that the claim is not admissible and does not provide coverage for pre-existing Condition. The Complainant states the rejection of claim is contrary to the terms of the policy, unfair and is against the principles of law. There is no basis for the rejection of the claim by the 2^nd Opposite Party. The Complainant issued a legal notice dated to the Opposite Parties. The Opposite Parties have received the notice and the 2^nd Opposite Party as on 15^th  January 2010 sent a reply stating that the treatment taken is of pre-existing nature and hence they are not liable to pay any compensation is not sustainable and prays to allow the Complaint with costs.

2.WRITTEN VERSION FILED  BY THE 1^st  OPPOSITE PARTY IN BRIEF:

          The factual matrix of the issue is that the Complainant/insured declared in the proposal form she has high Blood Pressure from last 10 years and also had angina 10 years back and other ailments and further in the policy issued by this party it was clearly mentioned that the insured had adverse medical history of High Blood Pressure, S.B.C. I.H.D. As per the policy terms and conditions the company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by the insured person in connection or in respect of all disease/injuries which are pre-existing  and related ailments are not covered. Admittedly insured had under gone treatment for hypertension and associated problems. Further the electrocardiogram shows anterolateral ischemia which is excluded as ischemia is pre-existing. The treatment being undergone being pre-existing nature the claim was not considered. For the reasons stated it is prayed that this Hon’ble Forum may be pleased to dismiss the Complaint in the interests of justice with costs.

3.POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

4. POINT NO:1

The case of the Complainant is that she took Ex.A2 Overseas Medical Claim Policy dated 13.10.2008 for the period 20.10.2008 to 17.01.2009 and she took treatment as per Ex.A5 at Overseas during the period 16.12.2008 to 06.01.2009 spending a sum of 2,61,738 chilean PESOS currency which is approximately comes to an Indian Rupee a sum of Rs.24,090.22 and to claim the said amount she filed Ex.A5 claim petition through the 2^nd Opposite Party and the policy issued by the 1^st Opposite Party  and the said policy was rejected by the Opposite Parties on the ground that the Complainant suffered with pre-existing disease which is not admissible to provide claim and rejection  made by the Opposite Parties is not sustainable since the policy is in force and therefore the Opposite Parties have committed Deficiency in Service.

5. The Opposite Party would contend that the claim made are not related to   the Complainant past medical history and therefore the rejection made by the Opposite Parties under Ex.A6 is sustainable.

6. Admittedly the 1^st Opposite Party issued the Ex.A2 policy for the period 20.10.2008 to 17.01.2009 to the Complainant and the said policy is an Overseas Medical Claim Policy. Before issuing the said policy the Complainant submitted Ex.A1 proposal form requesting the 1^st Opposite Party to issue Overseas Medical Claim Policy. In the said proposal form the Complainant clearly stated that she was suffering from disease more than 10 years and till  she is continuing the said treatment for such diseases. One of the disease she had clearly stated in the proposal form is an ANGINA which is related to heart disease. The Complainant took treatment in the overseas relating to heart disease only. The 1^st Opposite Party pleaded in the written version that the Electrocardiogram that shows Anterolateral Ischemia as Ischemia is pre-existing and therefore the treatment undergone pre-existing nature the claim was not considered. No proof filed by the Opposite Parties to show that Ischemia is a pre-existing disease to the Complainant. Further all the diseases the Complainant was undergoing treatment on the date of the submission of the proposal form clearly stated that she is continuing treatment for such diseases including heart disease. Therefore considering the above circumstances that the rejection made by the Opposite Parties is not sustainable and therefore we hold that the Opposite Parties have committed Deficiency in Service.

7. POINT NO:2

          Since Opposite Parties have committed Deficiency in Service in rejecting the claim, the claim made by the Complainant under Ex.A5 is entitled for a sum of Rs.24,090.22 rounded to Rs.24,090/-. The Complainant suffered with mental agony is accepted due to the rejection of the claim made by the Opposite Parties and therefore it would be appropriate to order a sum of Rs.25,000/- towards compensation for mental agony, besides a sum of Rs.5,000/- towards litigation expenses would meet ends of justice.

In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to pay the claim amount of Rs.24,090/- (Rupees twenty four thousand and ninety  only) to the Complainant towards Overseas Medical Expenses and also to pay a sum of Rs.25,000/- (Rupees twenty five thousand only)towards compensation for mental agony,  besides a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses.            The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 14^th  day of October 2016.

 

MEMBER – II                                                               PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated NIL                     Proposal form submitted by the Complainant –

                                                    Photocopy

Ex.A2 dated 13.10.2008                   Photocopy of Mediclaim Policy

Ex.A3 dated NIL                     Photocopy of International travel ticket

Ex.A4 dated 17.10.2008                   Printout ‘E’ Mail correspondence

Ex.A5 dated 30.01.2009                   Photocopy of claim submitted by the Complainant

                                                    along with the records

Ex.A6 dated 26.03.2009                   Photocopy of reply letter

Ex.A7 dated 05.05.2009                   Photocopy of rejoinder by the Complainant

Ex.A8 dated 11.05.2009                   Photocopy of reply to rejoinder

Ex.A9 dated 20.10.2009                   Photocopy of legal notice

Ex.A10 dated 15.01.2010       Photocopy of the reply to legal notice

Ex.A11 dated 02.02.2000       Dr.Sukumar’s Prescription

                   to 16.03.2011

Ex.A12 dated 05.07.2005       ECC Report

                   to 04.01.2012

Ex.A13 dated 15.02.2000       Echo Report

 

LIST OF DOCUMENTS FILED BY THE 1^st  OPPOSITE PARTY:

Ex.B1 dated NIL                     The Oriental Insurance Company Limited

                            

 

MEMBER – II                                                               PRESIDENT